In addition to these, the more ordinary associations of htemoptysis, it must be remembered that the sputa of pneumonia are really tinged with blood, which, though in the latter stages it acquire a brown or rusty color, may be in the first onset of a severe attack, quite florid in appearance. Conditions of congestion from gravitation, in fevers and blood diseases generally, may be accompanied by an oozing which gives the expectoration more or less of the same character. Bleeding from the lungs may also go along with other hemorrhages in cases of purpura htemorrhagica ; but such conditions, although they may rank htemoptysis as one of their symptoms, cannot be classed under that head.
Vicarious hemorrhage, in suppression of the habitual flow from the uterus, or of that from the htemorrhoidal vessels, is alleged sometimes to at on the characters of hremoptysis. Among females such a condition usually belongs to the spurious form ; the blood comes from the mouth and fences, and not from the lungs at all. It is very often entirely hysterical ; an excited fancy finding something in the teeth, the gums, or the throat to work upon, and the blood being really produced by suction. Strange to say, this incident very often occurs, without any intention of deception, at or about the time when the catamenia should have appeared ; probably from a notion being very widely spread among mothers and nurses that the blood is liable to "come some other way" in amenorrhma.
Well-authenticated cases of hemorrhage from the lungs for the relief of plethora, an event so common in the mucous membrane of the nose and the rectum, are very rare indeed. Perhaps scarcely one is on record which is unexceptionable ; at all events, the probability is very greatly against genuine haemoptysis depending on such a cause.
§ 3. Ihematemesis.—It is unnecessary again to go over the points which serve to distinguish between hemorrhage from the stomach, and hemorrhage from the lungs. The history must be our guide; and not whether the patient say he brought it up from his chest or his stomach ; a statement which, from the confused ideas gene rally entertained of the relation of internal organs, is quite value less : the question is, whether he felt sick or faint before he brought it up, or whether he had a cough. This faintness is often well marked, in consequence of a large quantity of blood being poured out into the stomach before its action is inverted so as to produce vomiting ; but this is by no means constant.
In quantity the blood is sometimes very considerable ; in con sistence clotted, or grumous, and mixed with the contents of the stomach ; in color it is almost always dark : occasionally the clots are partially decolorized, indicating that the blood has lain some time in the stomach. The formation of a true clot leads rather
to the suspicion that a vessel is ruptured ; but in any form of hemorrhage, where the quantity of blood poured out is great, it is more or less clotted. The action of the acid in the stomach has the effect of blackening the coloring matter ; but occasionally the discharge of blood goes on for so long that the stomach be comes entirely emptied of its natural secretion, and then the later efforts of vomiting bring up pure florid blood. This condition is that which is simulated by prolonged and profuse hiemoptysis when retching accompanies its advanced stage.
The blood in luematemesis is derived from three sources : (a) from erosion of a vessel; (b) by exudation from the surface of the mucous membrane ; (c) by oozing from a diseased portion of the stomach in cancerous formations.
a. Erosion of a vessel occurs either in consequence of ulceration of the mucous membrane, or from the pressure of an aneurism when it bursts into the stomach. Both forms of hemorrhage are severe, and very often fatal. Ulceration of the stomach, however, is generally preceded by symptoms of dyspepsia and a burning sensation after eating ; it is more common in young females than in males or persons of advanced age. The evidence of the exist ence of aneurism is less direct. (See Chap. IX., Div. H., I 2. Tumors.) The pressure which causes the absorption of tissue is generally attended with gnawing pain, which is pretty uniform in character.
b. Blood may exude from the surface of the mucous membrane under a variety of circumstances ; and this is especially associated with disease of the liver and spleen. In quantity often great, the exudation may go on for a considerable period, so that the stomach may be emptied three or four times in succession; the intervals are usually long, so that the color continues dark throughout. The age and habits of the patient are to be considered, as well as the evidence derived from other sources indicating hepatic or splenic disease. Hemorrhage from such causes very seldom occurs in early life, and persons of dissipated habits are more liable to it than others. Htematemesis is sometimes vicarious of menstruation: this is by far the most common and the best established of the instances of hemorrhage recurring at pretty regular intervals in cases of amenorrhoea; hence it is always important, when hornet emesis is present in a young female, to make inquiry into the state of the uterine functions.